CCFA Modules Sensistive Issues Inventory

7/28/2019 CCFA Modules Sensistive Issues Inventory

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Name: ______________________

Date: ______________________

Sensitive Issues Inventory

Confidential

Life can be tough. It is important to remember our past. You have to explore the tough things to successfully move forward to a better future. Below is alist of tough things that can happen to people.

Directions: Read each item. Circleyes, no or I dont know / Maybe/Maybe for each item.1. Have you ever been in a housefire? Yes No I dont know / Maybe

2. Have you ever been hurt in a fire or burned in any kind of

accident?

Yes No I dont know / Maybe

3. Have you ever been in a housefire that caused major damage toyour home?


4. Have you ever been in a tornado, hurricane, or flood thatcaused major damage to your home?


5. Have you ever been in a major car accident? Yes No I dont know / Maybe

6. Has a close family member (or close friend) ever been in a majorcar accident?


7. Have you ever been mugged or robbed at gun point? Yes No I dont know / Maybe

8. Has a close family member (or close friend) been mugged orrobbed at gun point?


9. Has your home ever been burglarized? Yes No I dont know / Maybe

10. Have you ever been raped? Yes No I dont know / Maybe

11. Has a close family member (or close friend) ever been raped? Yes No I dont know / Maybe

12. Have you ever been seriously hurt during a crime? Yes No I dont know / Maybe

13. Has a close family member (or close friend) ever been seriouslyhurt during a crime?


14. Has a family member (or close friend) ever been murdered? Yes No I dont know / Maybe

15. Are your parents separated or divorced? Yes No I dont know / Maybe

16. Have you ever been a member of a step-family? Yes No I dont know / Maybe

17. Does someone in your close family (or close friend) have adrinking problem?


Name: ______________________1. Does someone in your close family (or close friend) have a drug

problem?Yes No I dont know / Maybe


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19. Have you been sexually abused? Yes No I dont know / Maybe

20. Has a close family member (or close friend) sexually abused? Yes No I dont know / Maybe

21. Have you ever been physically abused? Yes No I dont know / Maybe

22, Has a close family member (or close friend) been physically

abused?


23, Have you been emotionally abused (severe criticism, verbalcruelty)?


24. Has a close family member (or close friend) been emotionallyabused?


25. Have you ever been physically neglected (not enough food, poorshelter etc.)?


26, Have you ever been in a combat situation either as a member of

the military or as a civilian?


27, Have you suffered from a serious medical condition? Yes No I dont know / Maybe

28, Has a close family member (or close friend) ever suffered from aserious medical condition?


29. Has a close family member (or close friend) died from a seriousmedical condition?


30 Has a close family member (or close friend) been diagnosed witha serious mental illness ?


31 Have you struggled with a serious eating disorder (Bulemia{eating and then taking laxatives or throwing up}. Anorexia Nervosa{starving yourself}, Obesity {overeating resulting in beingoverweight})?


32 Has a close family member (or close friend) struggled with aserious eating disorder disorder (Bulemia {eating and then takinglaxatives or throwing up} Anorexia Nervosa {starving yourself),Obesity {overeating resulting in being overweight})?


33 Have you ever seriously attempted suicide? Yes No I dont know / Maybe

34 Has a family member(or close friend) ever seriously attemptedsuicide?


35. Has a family member (or close friend) successfully committedsuicide?



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CCFA Modules Sensistive Issues Inventory